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导读：按服务收费（FeeforService）美国传统的医疗保险是一种按服务收费的医疗保险（FeeforServicePlan或者叫做IndemnityPlan）。您可以选择在任何时候，去任何医院诊所就诊。但您必须先支付所有的医疗费用。然后凭收据去保险公司报销。保险公司一般报销80％的医疗费用，您需要自己支付20％的费用。按服务收费的医疗保险比较昂贵。如果您不太在
按服务收费（Fee for Service）
美国传统的医疗保险是一种按服务收费的医疗保险（Fee for Service Plan 或者叫做 Indemnity Plan）。您可以选择在任何时候，去任何医院诊所就诊。但您必须先支付所有的医疗费用。然后凭收据去保险公司报销。保险公司一般报销80％的医疗费用，您需要自己支付20％的费用。 按服务收费的医疗保险比较昂贵。如果您不太在意保险的费用，而需要更多的选择余地，那么按服务收费的医疗保险可能适合您的需要。
管控型医疗保险（Managed Care）
目前在美国，大多数的私人医疗保险公司都属于管控型医疗保险
（Managed Care）。这种保险模式对医疗费用和投保人使用医疗保健服务都有限制。您在使用某些医疗服务前，如做医学检查，看专科医生，和住院治疗等，需经保险公司同意。否则保险公司可以拒绝支付医疗费用。此外若保险公司认定您使用的医疗服务超出合理范围，会要求投保人自己负担。
管控型医疗保险公司也对医疗服务提供方（医生医院等）的医疗行为进行控制，防止医生为自身利益滥用医疗服务。管控型的医疗保险有利于降低总体的医疗费用，但也可能影响病人及时获得合理的治疗。
在美国，主要有三大类管控型医疗保险公司：健康维护组织（Health Maintenance Organization，简称 HMO），优选医疗机构 (Preferred Provider Organization，简称PPO) ，以及定点服务组织
(Point-of-Service，简称POS) 。
健康维护组织（Health Maintenance Organization，HMO）健康维护组织（Health Maintenance Organization，HMO）是一种管理式的保险公司。HMO是管控型医疗保险计划中最便宜的类型。
HMO保险计划的保险费相对比较便宜，病人看病后自付费用的比例也较低。
HMO的目标是为每一个会员提供健康管理，强调通过预防性和综合协调医疗服务，提高投保人的整体健康水平，从而减少医疗费用。所以，HMO计划有更多预防性医疗的福利，如为会员提供免费的年度体检，疫苗注射，女性乳房检查等。
HMO的缺点是就医的选择性少。每个HMO都有自己的医生和医院网络，会员必须在网络内的医疗保健单位就医，保险公司才会报销相关的费用，急诊情况下除外。如果您在HMO指定网络外的医院或诊所就医，您则必须自费支付所有的费用。
此外，成为HMO会员后，保险公司会要求您指定一位医生作为您的基础保健医生（Primary Care Physician）。PCP 医生通常是家庭医生、内科医生、或儿科医生等。病人每次看病，必须首先去指定的医生处就诊。保健医生在某种意义上成为保险公司的看门人（Gatekeeper）。这是保险公司控制医疗费用的手段之一。
这种模式的优点是您的保健医生比较熟悉您的整体健康状况，能够协调治疗。缺点是，病人必须通过基础保健医生转诊才可以去看专科医生或住院治疗，有时候这种转诊方式可能拖延病人的治疗。
如果您需要就医的情况比较多，那么选择HMO的计划后您个人需要支付的医疗费用较低，可以相对节省看病的开支。
优选医疗机构保险 (Preferred Provider Organization，PPO)
优选医疗机构保险（Preferred Provider Organization，PPO）是介于按服务收费保险（Fee for Service）和健康维护组织（HMO）之间的一种自选式保险计划。PPO保险公司通过与医生医院谈判获得优惠的医疗服务价格。这样，PPO保险公司就可以向其会员提供更便宜的医疗保险。
参加PPO保险后，保险公司向会员提供一份优选医疗机构名单
（in-network providers）。会员可以从名单上选择自己喜爱的医生诊所。当您在网络内的医疗机构就诊时，您可以得到会员的优惠折扣价，保险公司将支付大部分的医疗费用。
PPO的会员也可以选择网络外的医疗机构（out-of-network providers），但个人自费的比例比较高，保险公司报销医疗费用的比例相应更低。而且，在网络外的医疗机构看病也不能获得医疗服务优惠折扣，这样医疗费用就更高。
PPO的优点是它给予您更多的选择性。投保人不需要指定基础保健医生，看专科医生也不需要通过基础保健医生转诊去看专科医生。
参加PPO保险计划有更多的选择医生医院的权利，但PPO的保险费通常比HMO更高。
指定医疗服务机构（Exclusive Provider Organization，EPO）
指定医疗服务机构 EPO 保险计划通常要求会员必须在保险公司指定的医疗服务网内就医。
保险不报销会员在医疗服务网之外就医的费用。有些 EPO 保险可能会对特殊情况下的紧急急诊根据具体的情况报销，但不保证一定会报销。
参加 EPO 保险计划后，一般不需要指定的基础保健医生（Primary Care Physician），看专科医生时可以不经过转诊。
EPO 保险计划的保险费和病人自己分担的医疗费用（自付、共同保险等）都比较低，是比较便宜的一种保险计划。但 EPO 保险计划只报销在其医疗服务网内的医疗费用，不报销在服务网外产生的医疗费用。病人在看病、做检查时最好向相关的医院、诊所、实验室等核实他们是否属于保险计划所指定的医疗服务网。
有些较便宜的 EPO 保险计划的医疗服务网络比较小，可供选择的医院诊所等医疗机构有限。
定点服务组织（Point-of-Service， POS）
定点服务组织(point-of-service， POS) 是一种结合HMO和PPO的保险形式。它比HMO有更多的选择性，同时也比PPO的费用更低。 POS也有自己的医疗保健网络。与HMO一样，POS的会员需要指定基础保健医生（Primary Care Physician）。在需要时，必须由您的基础保健医生将您转诊到保险公司指定网络内的专科医生，这样确保降低医疗费用。
如果您在POS的网络内就医，您个人支付的医疗费用比例较低，保险公司会承担大部分的费用。
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相关内容搜索/ What’s The Difference Between PPO, HMO, HDHP, POS, EPO?
What’s the difference between PPO, HMO, HDHP, POS, EPO?
By Les Masterson
Posted : October 21, 2016
URL: /health-insurance/difference-between-ppo-hmo-hdhp-pos-epo.html
plan is best for you?
The answer to that question really depends on a number of factors that pertain to your specific situation. When comparing health plan options, take these factors into account:
Your health
Your family&s health
Your health care providers and whether they accept the insurance
Your financial situation
Whether you want to pay more upfront via premiums
If you want flexibility and not having to ask for referrals to see a specialist
Once you review those factors, choosing a health plan is much easier.
The five most common types of health insurance plans are:
Preferred provider organizations (PPOs)
Health maintenance organizations (HMOs)
High deductible health plans (HDHPs)
Point of service plans (POS)
Exclusive provider organization plans (EPO)
The two most common health plans have been generally HMOs and PPOs, but HDHPs have become a lower-cost health insurance option for employers over the past decade. POS and EPO plans are options provided by some employers and health insurers, but they&re not nearly as common as HMOs, PPOs and HDHPs.
In this guide, we provide information about each of these plans to help you make the right decision for your circumstances. We will go through each of the five plan types and highlight the differences:
What is a PPO?
PPO stands for preferred-provider organization. Premiums and deductibles are usually much higher for a PPO compared to an HMO, but that comes with greater flexibility.
About one-half of enrollees in employer-based health plans are in a PPO. Though it remains the most utilized type of plan, the number has been falling in recent years as employers turn more to HDHPs as a way to contain health care costs.
You usually don&t have to select a PCP in a PPO plan, and you can choose from more healthcare providers than an HMO because PPO networks are usually larger. PPOs allow you to get both in-network and out-of-network care -- though out-of-network providers will be covered at a lesser percentage. You can also see a specialist without a referral.
Though a PPO gives you more independence, this doesn&t mean that you have complete access to the health care system without any oversight. A health plan may still require you and a physician to get approval for a costly service, such as an MRI.
In addition to higher premiums, PPOs usually have a deductible that you have to meet before the health plan pays for care.
reports the average deductible for an individual PPO plan is $1,028. Once you&ve reached your deductible, your insurer begins to pick up its portion of the coinsurance.
The plans also include an out-of-pocket maximum for in-network care. If you reach your out-of-pocket maximum, all costs are covered by your insurer. A plan&s out-of-pocket maximum can vary widely, so you&ll need to check to see the out-of-pocket maximum for your plan. For Marketplace plans through , the maximum out-of-pocket limits for 2017 are $7,150 for an individual plan and $14,300 for a family plan.
The main benefit of a PPO is flexibility, but it does come at the cost of higher premiums and a deductible that you will have to pay before your insurer starts paying for care.
When a PPO might be right for you:
You want the flexibility to go out of network and not need to get referrals.
Flexibility is more important to you than paying higher premiums.
You would rather pay higher premiums, but likely pay less for the health care services.
What kind of person should opt for a PPO: Someone who utilizes health care regularly and sees specialists or wants to have the option to see a specialist without getting a referral.
What is an HMO?
HMO stands for health maintenance organization and makes up about 15 percent of health plans. It is known for its lower premiums and restricted network of doctors and hospitals, which means you sacrifice flexibility for lower upfront costs.
You&ll likely pay less in premiums for an HMO compared to a PPO & sometimes significantly less.
HMOs require that you name a primary care physician (PCP) who &coordinates& care, meaning your primary doctor must refer you first in order to see a specialist. HMOs usually don&t have deductibles (or they are lower than other plans). Instead, you pay copays for office visits, tests and prescriptions.
One drawback to an HMO is that these plans usually don&t allow you to go outside your network for care. If you do, you&ll need to pay for the care on your own. An exception is if you need emergency care, which requires the facility (but not necessarily the providers) to bill as in network.
Not all providers accept HMOs, so before choosing an HMO, make sure your provider or providers accept the plan.
When an HMO might be right for you:
You have a primary care physician and other providers who are in the HMO network.
You don&t see many specialists and don&t need referrals often.
You don&t mind the limitations of only seeing providers in your network.
Cost is more important to you than flexibility.
What kind of person should opt for a HMO:& Someone who wants to pay as little as possible in premiums though not have to face high deductibles. An HMO could be a good option if you have a PCP and your other health care providers are already in the HMO.
What is an HDHP?
HDHP stands for high-deductible health plan, which is also sometimes called a CDHP (consumer driven health plan). HDHPs have grown in popularity as more employers have begun offering the plans as a way to contain health care costs.
Nearly one-third of workers have a HDHP.
Unlike the other plans, an HDHP can vary depending on the specific plan. For instance, one HDHP could be very similar to an HMO, while another could look more like a PPO. The critical piece of a HDHP is the size of the deductible and Health Savings Account that is attached to it.
The deductible is usually higher in an HDHP compared to other plans. The IRS defines a HDHP as any plan with a deductible of at least $1,300 for an individual and $2,600 for a family. You need to pay that amount for care before your health insurance chips in.
The average HDHP deductible is a little more than $2,000, but one-fifth of HDHP plan enrollees have a deductible of more than $3,000, according to the Kaiser Family Foundation.
You&ll want to keep that in mind if you choose this plan, and you should set aside money for the deductible in case you need it.
HDHPs typically feature a Health Savings Account, which allows you to save money pre-tax to pay for qualified medical expenses. Some employers seed money in employee HSA accounts to help pay for care, so you&ll want to see if your employer provides money to employee HSAs when making a health plan decision.
Much like a PPO, your insurer will begin to pay its share of the coinsurance once you&ve reached your deductible. Your insurer will cover all costs once you&ve hit your out-of-pocket maximum.
HDHP usually have lower premiums, so they can be a less costly plan option -- as long as you don&t need a lot of medical care. HDHPs might be a good idea if you are young and healthy, but could be costly to older adults or young families.
Before deciding on an HDHP, think about your next year of potential health care costs to see whether the lower premiums will more than offset the potential costs of care.
When a HDHP might be right for you:
You don&t have many health care costs, and you don&t expect to have many costs over the next year.
You&d rather pay less upfront costs in premiums with the understanding that the higher deductible means you&ll pay more out-of-pocket if you need care.
You don&t have children and/or a spouse on your plan who may use a lot of health care services.
What kind of person should opt for a HDHP: Someone who is healthy and doesn&t expect to use many health care services within the next year. You want the cheapest premiums and don&t mind having to pay a high deductible if you need a lot of care.
What is a POS?
POS stands for point of service plan and makes up about 10 percent of health plans. POS plans are not nearly as common as PPOs, HDHPs and HMOs. POS plans are a hybrid of PPO and HMOs. In fact, point of service means that the health care consumer gets to choose whether to use HMO or PPO services each time you see a provider.
POS plans usually have similar rules to HMOs (for instance, you need to choose an in-network physician as your PCP), but you can see an out-of-network physician for a higher fee in a POS plan.
When a POS might be right for you:
You have a PCP in the POS plan.
You want the flexibility of going out of network like a PPO -- and don&t mind paying the higher out-of-pocket fees when you need to go out of network.
You&re good at keeping health care receipts. You don&t mind filling out forms and sending in bills for payment if you get care out of network.
What kind of person should opt for a POS: Someone who likes being able to go out of network for care, but also wants a PCP coordinating your care.
What is an EPO?
EPO stands for exclusive provider organization and is a managed care plan that requires you to go to doctors and hospitals in the plan&s network.
You don&t need to choose a PCP or need a referral, so in that sense, it&s similar to a PPO, but you will only receive coverage for providers in your network. Other parts of an EPO plan are similar to an HMO, such as having a limited network of doctors and hospitals. You can&t get care outside the network unless it&s an emergency.
Much like a PPO, you need to get approval from your health plan in order to get what&s deemed as an expensive service.
When an EPO might be right for you:
You want the flexibility of a PPO and don&t need a referral as long as you stay in network.
You&re OK having a limited network of doctors and facilities like an HMO.
You want a network like an HMO, but don&t want to choose a PCP.
What kind of person should opt for an EPO: Someone who doesn&t mind have a limited number of doctors and facilities and would rather not have to get a referral to see a specialist.
What is the difference between HMO, PPO, HDHP, POS and EPO?
season at your job and your employer offers you a choice between the three biggest plan types: HMO, PPO and HDHP. Which is best? It really depends on your financial and medical situation & and preferences.
For instance, would you rather the flexibility of not having to go to a smaller group of providers in an HMO and don&t mind paying more upfront for your care via premiums? Then, a PPO might be right for you.
Do you not care about having a large network of providers, but paying as little as possible for health care is more important to you? Then, an HMO could be perfect.
Do you not use medical services often and you want a plan that will protect you, but not cost much in terms of upfront premiums? Then, a HDHP could be the direction to go.
Choosing the right health insurance plan is a personal decision and depends on your situation and preferences. Whether you ultimately choose a PPO, HMO, HDHP, POS or EPO, take costs, flexibility, coverage and convenience into account when making that decision.
Type of planAverage deductible*Require PCP?Need referrals?Out of network care
Yes, but costlier
*Kaiser Family Foundation, 2016 Employer Health Benefits Survey. Note: The survey did not include the average deductible amount for an EPO.
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950 Tower Ln, Suite 600, Foster City 94404健康维护组织（Health Maintenance Organization，HMO）是一种管理式的保险公司。HMO是管控型医疗保险计划中最便宜的类型。HMO保险计划的保险费相对比较便宜，病人看病后自付费用的比例也较低。
HMO的目标是为每一个会员提供健康管理，强调通过预防性和综合协调医疗服务，提高投保人的整体健康水平，从而减少医疗费用。所以，HMO计划有更多预防性医疗的福利，如为会员提供免费的年度体检，疫苗注射，女性乳房检查等。
HMO的缺点是就医的选择性少。每个HMO都有自己的医生和医院网络，会员必须在网络内的医疗保健单位就医，保险公司才会报销相关的费用，急诊情况下除外。如果您在HMO指定网络外的医院或诊所就医，您则必须自费支付所有的费用。
此外，成为HMO会员后，保险公司会要求您指定一位医生作为您的基础保健医生（Primary Care Physician）。PCP 医生通常是家庭医生、内科医生、或儿科医生等。病人每次看病，必须首先去指定的医生处就诊。保健医生在某种意义上成为保险公司的看门人（Gatekeeper）。这是保险公司控制医疗费用的手段之一。
这种模式的优点是您的保健医生比较熟悉您的整体健康状况，能够协调治疗。缺点是，病人必须通过基础保健医生转诊才可以去看专科医生或住院治疗，有时候这种转诊方式可能拖延病人的治疗。
如果您需要就医的情况比较多，那么选择HMO的计划后您个人需要支付的医疗费用较低，可以相对节省看病的开支。
优选医疗机构保险（Preferred Provider Organization，PPO）是介于按服务收费保险（Fee for Service）和健康维护组织（HMO）之间的一种自选式保险计划。PPO保险公司通过与医生医院谈判获得优惠的医疗服务价格。这样，PPO保险公司就可以向其会员提供更便宜的医疗保险。
参加PPO保险后，保险公司向会员提供一份优选医疗机构名单（in-network providers）。会员可以从名单上选择自己喜爱的医生诊所。当您在网络内的医疗机构就诊时，您可以得到会员的优惠折扣价，保险公司将支付大部分的医疗费用。
PPO的会员也可以选择网络外的医疗机构（out-of-network providers），但个人自费的比例比较高，保险公司报销医疗费用的比例相应更低。而且，在网络外的医疗机构看病也不能获得医疗服务优惠折扣，这样医疗费用就更高。
PPO的优点是它给予您更多的选择性。投保人不需要指定基础保健医生，看专科医生也不需要通过基础保健医生转诊去看专科医生。
参加PPO保险计划有更多的选择医生医院的权利，但PPO的保险费通常比HMO更高。
指定医疗服务机构（Exclusive Provider Organization，EPO）通常要求会员必须在保险公司指定的医疗服务网内就医。
保险不报销会员在医疗服务网之外就医的费用。有些 EPO 保险可能会对特殊情况下的紧急急诊根据具体的情况报销，但不保证一定会报销。
参加 EPO 保险计划后，一般不需要指定的基础保健医生（Primary Care Physician），看专科医生时可以不经过转诊。
EPO 保险计划的保险费和病人自己分担的医疗费用（自付、共同保险等）都比较低，是比较便宜的一种保险计划。但 EPO 保险计划只报销在其医疗服务网内的医疗费用，不报销在服务网外产生的医疗费用。病人在看病、做检查时最好向相关的医院、诊所、实验室等核实他们是否属于保险计划所指定的医疗服务网。
有些较便宜的 EPO 保险计划的医疗服务网络比较小，可供选择的医院诊所等医疗机构有限。
定点服务组织(point-of-service， POS) 是一种结合HMO和PPO的保险形式。它比HMO有更多的选择性，同时也比PPO的费用更低。
POS也有自己的医疗保健网络。与HMO一样，POS的会员需要指定基础保健医生（Primary Care Physician）。在需要时，必须由您的基础保健医生将您转诊到保险公司指定网络内的专科医生，这样确保降低医疗费用。
如果您在POS的网络内就医，您个人支付的医疗费用比例较低，保险公司会承担大部分的费用。
与HMO不同的是，POS的会员也可以自己直接到POS网络外的专科医生诊所就诊。在这种情况下，POS保险公司也会报销您的部分医疗费用，但病人需要自己支付的自付款（deductible）和共同付款（co-payment）部分相对较高。所以，POS具有HMO的较低保险费的优势，但也给了会员更多自主就医的选择。
Requires PCP需要选定家庭医生
Requires referrals看专科需要转诊单
Requires pre-authorization某些服务需要保险公司预先审批
Pays for out-of-network care网络外医生包不包
Cost-sharing
共同分摊费用
Do you have to file claim paperwork？需要自己向医保公司理赔
Not usually required. If required, PCP does it. 通常不需要，可以家庭医生来做。
Not usually. If required, PCP likely does it. Out-of-network care may have different rules.通常不需要，可以家庭医生来做。看网络外的医生的话，可能不同·
Yes, but requires PCP referral.
包，要家庭医生写转诊单
Low in-network, high for out-of-network.网络中的医生低，网络外的医生高。
Only for out-of-network claims.看网络外的医生的话要
High, especially for out-of-network care. 高，尤其网络外的医生
Only for out-of-network claims.看网络外的医生的话要
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